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[en] This Hands-on Workshop will be focused on providing participants with experience with the principal tools of TG 100 and hence start to build both competence and confidence in the use of risk-based quality management techniques. The three principal tools forming the basis of TG 100’s risk analysis: Process mapping, Failure-Modes and Effects Analysis and fault-tree analysis will be introduced with a 5 minute refresher presentation and each presentation will be followed by a 30 minute small group exercise. An exercise on developing QM from the risk analysis follows. During the exercise periods, participants will apply the principles in 2 different clinical scenarios. At the conclusion of each exercise there will be ample time for participants to discuss with each other and the faculty their experience and any challenges encountered. Learning Objectives: To review the principles of Process Mapping, Failure Modes and Effects Analysis and Fault Tree Analysis. To gain familiarity with these three techniques in a small group setting. To share and discuss experiences with the three techniques with faculty and participants. Director, TreatSafely, LLC. Director, Center for the Assessment of Radiological Sciences. Occasional Consultant to the IAEA and Varian.
[en] Purpose: To demonstrate significant organ-at-risk (OAR) sparing achievable with 4π non-coplanar radiotherapy on spine SBRT and SRS patients. Methods: Twenty-five stereotactic spine cases previously treated with VMAT (n = 23) or IMRT (n = 2) were included in this study. A computer-aided-design model of a Linac with a 3D-scanned human surface was utilized to determine the feasible beam space throughout the 4π steradian and beam specific source-to-target-distances (STD) required for collision avoidance. 4π radiotherapy plans integrating beam orientation and fluence map optimization were then created using a column-generation algorithm. Twenty optimal beams were selected for each case. To evaluate the tradeoff between dosimetric benefit and treatment complexity, 4π plans including only isocentrically deliverable beams were also created. Beam angles of all standard and isocentric 4π plans were imported into Eclipse to recalculate the dose using the same calculation engine as the clinical plans for unbiased comparison. OAR and PTV dose statistics for the clinical, standard-4π, and isocentric-4π plans were compared. Results: Comparing standard-4π to clinical plans, particularly significant average percent reduction in the [mean, maximum] dose of the cord and esophagus of [41%, 21.7%], and [38.7%, 36.4%] was observed, along with global decrease in all other OAR dose statistics. The average cord volume receiving more than 50% prescription dose was substantially decreased by 76%. In addition, improved PTV coverage was demonstrated with a maximum dose reduction of 0.93% and 1.66% increase in homogeneity index (D95/D5). All isocentric-4π plans achieved dosimetric performance equivalent to that of the standard-4π plans with higher delivery complexity. Conclusion: 4π radiotherapy significantly improves stereotactic spine treatment dosimetry. With the substantial OAR dose sparing, PTV dose escalation is considerably safer. Isocentric-4π is sufficient to achieve the dosimetric gain. The successful implementation of 4π using an FDA approved planning system paves the way for a prospective clinical trial. Varian Medical Systems, NIH R43CA183390 and R01CA188300, NSF graduate research fellowship DGE-1144087
[en] Purpose: To develop an efficient and effective trajectory optimization methodology for 4π dynamic conformal arc treatment (4π DCAT) with synchronized gantry and couch motion; and to investigate potential clinical benefits for stereotactic body radiation therapy (SBRT) to breast, lung, liver and spine tumors. Methods: The entire optimization framework for 4π DCAT inverse planning consists of two parts: 1) integer programming algorithm and 2) particle swarm optimization (PSO) algorithm. The integer programming is designed to find an optimal solution for arc delivery trajectory with both couch and gantry rotation, while PSO minimize a non-convex objective function based on the selected trajectory and dose-volume constraints. In this study, control point interaction is explicitly taken into account. Beam trajectory was modeled as a series of control points connected together to form a deliverable path. With linear treatment planning objectives, a mixed-integer program (MIP) was formulated. Under mild assumptions, the MIP is tractable. Assigning monitor units to control points along the path can be integrated into the model and done by PSO. The developed 4π DCAT inverse planning strategy is evaluated on SBRT cases and compared to clinically treated plans. Results: The resultant dose distribution of this technique was evaluated between 3D conformal treatment plan generated by Pinnacle treatment planning system and 4π DCAT on a lung SBRT patient case. Both plans share the same scale of MU, 3038 and 2822 correspondingly to 3D conformal plan and 4π DCAT. The mean doses for most of OARs were greatly reduced at 32% (cord), 70% (esophagus), 2.8% (lung) and 42.4% (stomach). Conclusion: Initial results in this study show the proposed 4π DCAT treatment technique can achieve better OAR sparing and lower MUs, which indicates that the developed technique is promising for high dose SBRT to reduce the risk of secondary cancer.
[en] Purpose: To develop a modern, patient-comfortable total body irradiation (TBI) technique suitable for standard-sized linac vaults. Methods: An indexed rotatable immobilization system (IRIS) was developed to make possible total-body CT imaging and radiation delivery on conventional couches. Treatment consists of multi-isocentric volumetric modulated arc therapy (VMAT) to the upper body and parallel-opposed fields to the lower body. Each isocenter is indexed to the couch and includes a 180° IRIS rotation between the upper and lower body fields. VMAT fields are optimized to satisfy lung dose objectives while achieving a uniform therapeutic dose to the torso. End-to-end tests with a rando phantom were used to verify dosimetric characteristics. Treatment plan robustness regarding setup uncertainty was assessed by simulating global and regional isocenter setup shifts on patient data sets. Dosimetric comparisons were made with conventional extended distance, standing TBI (cTBI) plans using a Monte Carlo-based calculation. Treatment efficiency was assessed for eight courses of patient treatment. Results: The IRIS system is level and orthogonal to the scanned CT image plane, with lateral shifts <2mm following rotation. End-to-end tests showed surface doses within ±10% of the prescription dose, field junction doses within ±15% of prescription dose. Plan robustness tests showed <15% changes in dose with global setup errors up to 5mm in each direction. Local 5mm relative setup errors in the chest resulted in < 5% dose changes. Local 5mm shift errors in the pelvic and upper leg junction resulted in <10% dose changes while a 10mm shift error causes dose changes up to 25%. Dosimetric comparison with cTBI showed VMAT-TBI has advantages in preserving chest wall dose with flexibility in leveraging the PTV-body and PTV-lung dose. Conclusion: VMAT-TBI with the IRIS system was shown clinically feasible as a cost-effective approach to TBI for standard-sized linac vaults.
[en] Purpose: Respiration causes lesion smearing, image blurring and quality degradation, affecting lesion contrast and the ability to define correct lesion size. The spatial resolution of current multi pinhole SPECT (MPHS) scanners is sub-millimeter. Therefore, the effect of motion is more noticeable in comparison to conventional SPECT scanner. Gated imaging aims to reduce motion artifacts. A major issue in gating is the lack of statistics and individual reconstructed frames are noisy. The increased noise in each frame, deteriorates the quantitative accuracy of the MPHS Images. The objective of this work, is to enhance the image quality in 4D-MPHS imaging, by 4D image reconstruction. Methods: The new algorithm requires deformation vector fields (DVFs) that are calculated by non-rigid Demons registration. The algorithm is based on the motion-incorporated version of ordered subset expectation maximization (OSEM) algorithm. This iterative algorithm is capable to make full use of all projections to reconstruct each individual frame. To evaluate the performance of the proposed algorithm a simulation study was conducted. A fast ray tracing method was used to generate MPHS projections of a 4D digital mouse phantom with a small tumor in liver in eight different respiratory phases. To evaluate the 4D-OSEM algorithm potential, tumor to liver activity ratio was compared with other image reconstruction methods including 3D-MPHS and post reconstruction registered with Demons-derived DVFs. Results: Image quality of 4D-MPHS is greatly improved by the 4D-OSEM algorithm. When all projections are used to reconstruct a 3D-MPHS, motion blurring artifacts are present, leading to overestimation of the tumor size and 24% tumor contrast underestimation. This error reduced to 16% and 10% for post reconstruction registration methods and 4D-OSEM respectively. Conclusion: 4D-OSEM method can be used for motion correction in 4D-MPHS. The statistics and quantification are improved since all projection data are combined together to update the image.
[en] Purpose: To develop Monte Carlo models of cell clusters to investigate the relationships between macro- and microscopic dose descriptors, quantify the microdosimetric spread in energy deposition for subcellular targets, and determine how these results depend on the computational model. Methods: Microscopic tissue structure is modelled as clusters of 13 to 150 cells, with cell (nuclear) radii between 5 and 10 microns (2 and 9 microns). Energy imparted per unit mass (specific energy or dose) is scored in the nucleus (Dnuc) and cytoplasm (Dcyt) for incident photon energies from 20 to 370 keV. Dose-to-water (Dw,m) and dose-to-medium (Dm,m) are compared to Dnuc and Dcyt. Single cells and single nuclear cavities are also simulated. Results: Dnuc and Dcyt are sensitive to the surrounding environment with deviations of up to 13% for a single nucleus/cell compared with a multicellular cluster. These dose descriptors vary with cell and nucleus size by up to 10%. Dnuc and Dcyt differ from Dw,m and Dm,m by up to 32%. The microdosimetric spread is sensitive to whether cells are arranged randomly or in a hexagonal lattice, and whether subcellular compartment sizes are sampled from a normal distribution or are constant throughout the cluster. Conclusions: Dnuc and Dcyt are sensitive to cell morphology, elemental composition and the presence of surrounding cells. The microdosimetric spread was investigated using realistic elemental compositions for the nucleus and cytoplasm, and depends strongly on subcellular compartment size, source energy and dose.
[en] Purpose: egs_brachy is a fast, new EGSnrc user-code for brachytherapy applications. This study characterizes egs_brachy features that enhance simulation efficiency. Methods: Calculations are performed to characterize efficiency gains from various features. Simulations include radionuclide and miniature x-ray tube sources in water phantoms and idealized prostate, breast, and eye plaque treatments. Features characterized include voxel indexing of sources to reduce boundary checks during radiation transport, scoring collision kerma via tracklength estimator, recycling photons emitted from sources, and using phase space data to initiate simulations. Bremsstrahlung cross section enhancement (BCSE), uniform bremsstrahlung splitting (UBS), and Russian Roulette (RR) are considered for electronic brachytherapy. Results: Efficiency is enhanced by a factor of up to 300 using tracklength versus interaction scoring of collision kerma and by up to 2.7 and 2.6 using phase space sources and particle recycling respectively compared to simulations in which particles are initiated within sources. On a single 2.5 GHz Intel Xeon E5-2680 processor cor, simulations approximating prostate and breast permanent implant ((2 mm)3 voxels) and eye plaque ((1 mm)3) treatments take as little as 9 s (prostate, eye) and up to 31 s (breast) to achieve 2% statistical uncertainty on doses within the PTV. For electronic brachytherapy, BCSE, UBS, and RR enhance efficiency by a factor >2000 compared to a factor of >104 using a phase space source. Conclusion: egs_brachy features provide substantial efficiency gains, resulting in calculation times sufficiently fast for full Monte Carlo simulations for routine brachytherapy treatment planning.
[en] Purpose: This retrospective study aims to quantify the positional accuracy of seed delivery in permanent breast seed implant (PBSI) brachytherapy at the Tom Baker Cancer Centre (TBCC). Methods: Treatment planning and post-implant CT scans for 5 patients were rigidly registered using the MIM Symphony™ software (MIM Software, Cleveland, OH) and used to evaluate differences between planned and implanted seed positions. Total and directional seed displacements were calculated for each patient in a clinically relevant ‘needle coordinate system’, defined relative to the angle of fiducial needle insertion. Results: The overall average total seed displacement was 10±8 mm. Systematic seed displacements were observed in individual patients and the magnitude and direction of these offsets varied among patients. One patient showed a significant directional seed displacement in the shallow-deep direction compared with the other four patients. With the exception of this one patient outlier, no significant systematic directional displacements in the needle coordinate system were observed for this cohort; the average directional displacements were −1±5 mm, 2±3 mm, and −2±4 mm in the shallow-deep, up-down, and right-left directions respectively. Conclusion: With the exception of one patient outlier, the magnitude of seed displacements were relatively consistent among patients. The results indicate that the shallow-deep direction possesses the largest uncertainty for the seed delivery method used at the TBCC. The relatively large uncertainty in seed placement in this direction is expected, as this is the direction of needle insertion. Further work will involve evaluating deflections of delivered needle tracks from their planned positions.
[en] An Eckert & Ziegler Bebig Co0.A86 cobalt 60 high dose rate (HDR) brachytherapy source was commissioned for clinical use. Long-lived Co-60 HDR sources offer potential logistical and economic advantages over Ir-192 sources, and should be considered for low to medium workload brachytherapy departments where modest increases in treatment times are not a factor. In optimized plans, the Co-60 source provides a similar dose distribution to Ir-192 despite the difference in radiation energy. By switching to Co-60, source exchange frequency can be reduced by a factor of 20, resulting in overall financial savings of more than 50% compared to Ir-192 sources. In addition, a reduction in Physicist QA workload of roughly 200 hours over the 5 year life of the Co-60 source is also expected. These benefits should be considered against the modest increases in average treatment time compared to those of Ir-192 sources, as well as the centre-specific needs for operating room shielding modification.